1. Spring 2015 Kyle Stephenson
Clinical Psychology
Spring 2015
Kyle Stephenson
Should use part of the class session to practice basic interview skills.
Use only reflections
Use only open-ended questions
Repeating vs. reflection (getting at emotional tone, not just content)

2. Overview – Day 5 Goals of assessment Rapport Listening
Types of interviews
General intake
Mental status exam
Diagnostic interview
Reliability & validity of interviews
Last class, we learned about the ultimate outcome of much of psychological assessment: the diagnosis. Now, we’re going to dive into the nuts and bolts of how psychologists come to that diagnosis. Today, we’re going to cover the general tools that are most commonly used – the face-to-face clinical interview. After this, we’ll talk more about specific types of assessment – intelligence, personality, projective, and behavioral.
The reason we spend so much time on assessment is because assessment shapes everything we do as clinicians. Clinicians are scientists, even if nothing they do ends up in a peer-reviewed journal. We’re scientists because we use the scientific method when treating clients. We gather information, construct hypotheses, test those hypotheses, then refine our theories of how and why things are happening in the world. In the case of clinical practice, we gather this information through assessment, the diagnosis is essentially our hypothesis, and the treatment consists of multiple tests of this hypothesis. E.g., based on my assessment of John, I believe that he has social anxiety disorder… based on what we know about social anxiety disorder, XYZ factors should be maintaining his distress and impairment… if this is true, he should benefit from XYZ interventions… If he does, great! If he doesn’t, we need to revise our theory of either social anxiety disorder, or whether this diagnostic label fits for John.

3. Assessment in Clinical Psychology
Clinical assessment involves
evaluation of an individual’s strengths and weaknesses
conceptualization of the problem (including possible causative and maintaining factors)
prescription for alleviating the problem
Three big goals of assessment – learn about the person, learn about the problem, come up with a plan of how to improve the problem. It’s important to note that this improvement could come in multiple forms:
Eliminating causative or maintaining factors (e.g., changing fear structures and cognitive schemas)
Decreasing negative impact of symptoms (e.g., change behaviors to engage in valued activities despite anxiety)
Increase strengths/protective factors (e.g., increase understanding and empathy between relational partners despite ongoing differences and disagreements)
So, we tend to focus not just on things going wrong, but also what is going well and strengths that can be built up.

4. Assessment in Clinical Psychology
What influences how the clinician addresses the referral question?
Clinician’s theoretical orientation
Psychodynamic, cognitive-behavioral, etc.
Choice of assessment instruments
Theoretical orientation impacts which assessment tools the clinician will use
But, how do we get there? It will actually look pretty different depending on the clinician. Two big factors are the theoretical orientation and the specific assessment instruments used.
A psychodynamic clinician believes that the root causes of psychopathology are related to childhood development, so he/she will spend much more time gathering information about childhood. Also, he/she would believe that the individual’s difficulties are at least partly outside of conscious awareness, so it would make less sense to use a lot of explicit self report measures and more sense to use projective tests and the clinician’s own sense of the client’s unconscious conflicts. In contrast, a CBT therapist would spend more time exploring current patterns of thinking and behavior, having the client engage in a lot of monitoring of their own processes.

5. Overview – Day 5 Goals of assessment Rapport Listening
Types of interviews
General intake
Mental status exam
Diagnostic interview
Reliability & validity of interviews
This is all well and good, but you also need the client on your side to complete this process. You don’t need to be bff’s, but there are multiple aspects of the relationship that constitute a necessary foundation for both assessment and later intervention.

6. The Interview Rapport Relationship between patient and clinician
Acceptance
Empathy
Understanding
Respect
Competence
Multiple components of rapport, which can generally be thought of as the working relationship between therapist and client.
Acceptance – Opposite of judgment, essentially an unconditional willingness to be open to whatever the client’s experience is without labeling it as wrong, bad, etc. This often requires setting aside of your world-view and values. E.g., therapy with someone who has sexually abused a child, therapy with someone who has racist beliefs. Key is to understand how/why a behavior came to be and how it serves the person (e.g., was abuse the only way the person learned to express caring? Do racist beliefs help protect against traumatic memories being triggered?). You’ll see that all of these aspects of rapport tend to intermingle.
Empathy - different from sympathy. Not feeling bad for someone, but feeling bad with someone. Empathy can be thought of as a genuine, visceral understanding of what the other person is feeling. Not a yes/no proposition, but rather on a continuum with increasing empathy being built over time.
Understanding – Full understanding of emotional experience (perfect empathy) is usually not possible, even if you’ve had the same experiences. However, your job as the therapist is to try and understand as much as you can while still staying on track to actually help the person. An important point in my view – a common misunderstanding is that understanding is the goal of the therapy. Instead, understanding is a necessary pre-condition to good rapport, which is itself a precondition to effectively implementing therapeutic interventions.
Respect – As a therapist, you’re typically seeing someone at their worst. They’ve tried everything else and are in a place where they’re feeling lost, incompetent, etc. In other words, you don’t get to see much of the person’s strengths firsthand because they don’t need as much help with those! This situation makes it relatively easier to see someone as weak/stupid etc., even for a very compassionate therapist! So, it’s very important not to only focus on what a person is doing that is not working well, but to acknowledge their effort, abilities, etc.
Competence – your job as a psychologist is to get yourself fired. The general way to do this is to increase the client’s competence in using their existing coping tools and expanding their range of tools. An important point is that the therapy is not about you, but about the client. The best interventions should result in the clients seeing their own abilities, not show off your ability as a therapist.

7. Overview – Day 5 Goals of assessment Rapport Listening
Types of interviews
General intake
Mental status exam
Diagnostic interview
Reliability & validity of interviews

8. Listening Active listening The basics Reflections Validation Questions
What not to do
The basics
Non-verbals: Eye contact, posture, nodding
Reflections
Paraphrasing vs. reflecting emotions
Summaries
Identifying themes
Validation
Questions
So few good example videos!
Active listening is a set of tools for gaining and showing understanding and empathy. It is important for you to get information from the person, but the MORE important part of active listening is making the person feel heard. Even if you perfectly understand where they’re coming from, it doesn’t matter unless they know that.
Most of the non-verbals are meant to communicate that what the person is saying is important to you. Most future therapists do these anyway as they tend to happen naturally when you’re actually interested! But, most people have something unique to them that they usually need to work on. It could be fidgeting around a lot, always looking at the ceiling when you’re thinking, etc. These things aren’t “bad” per se but they can distract the client, disrupt the flow of conversation, etc.
Reflections are super important because they allow you to guide the conversation without explicitly re-directing. They also allow you to show your understanding in a very straightforward way. There are multiple levels of complexity when it comes to reflections. The most basic is paraphrasing, which involves reflecting content. A “full” reflection is more than paraphrasing because it includes not just surface-level content, but also emotional content. This often involves going a bit beyond what the person technically said.
A summary provides a structure for surface level and emotional content. E.g., “Let me make sure I’m understanding what you’ve been talking about…”
Identifying themes is a more advanced skill where you reflect a person’s core concerns, beliefs, or typical ways of thinking across multiple domains.
Validation is distinct from agreement. It’s essentially saying that the person’s emotions make sense, and that they have a right to them. This doesn’t mean that resulting behaviors are “right,” and in fact could be very disruptive. But, validation requires finding some type of explanation for the emotions – “if anyone with your background and experiences were in X situation, of course they would feel Y.”
Pairs of students, listener using only reflections (no questions)
Prompts:
Discuss something in school that is stressing you out
Discuss a change you’d like to make to your health behaviors (diet, exercise, etc.)
Discuss a recent accomplishment you feel proud of

9. Overview – Day 5 Goals of assessment Rapport Listening
Types of interviews
General intake
Mental status exam
Diagnostic interview
Reliability & validity of interviews

10. Intake interview Goals: Build rapport
Identify presenting problem – symptoms, severity, and course
Identify client’s goals
Learn about previous mental health treatments
Collect background information (psychosocial history)
Instill hope!
Typically 1st contact, so often need to prioritize rapport over information gathering
Hope: could be the first time they have ever talked about these problems to anyone. You simply not reacting negatively is often a huge surprise, but even better if you can validated and let them know that you as a psychologist not only understand what they’re going though, but can also help.

11. Varieties of Interviews
The Mental Status Examination Interview
Goals:
Establish client’s basic abilities and awareness
Identify major cognitive deficits that preclude other types of standard interviews
More common in hospitals – often just assumed in private practice and other settings.

12. The Mental Status Examination Interview
General presentation: appearance, behavior, attitude
State of consciousness: alert, hyperalert, lethargic
Attention and concentration
Speech: charity, goal- directedness, language deficits
Orientation: to person, place, time
Mood and affect
Form of thought; formal thought disorder
Thought content: preoccupations, obsessions, delusions
Ability to think abstractly
Perceptions: hallucinations
Memory: immediate, recent, remote
Intellectual functioning
Insight and judgment
Examples of something that would be noteworthy:
Appearance – disheveled, poor hygiene
Behavior – eye contact, willingness to complete assessment
Attitude – open vs. suspicious
Consciousness – nodding off, repeatedly getting out of chair
Attention – cannot follow line of conversation
Speech – circumstantial, tangential
Orientation – does not know where he/she is
Mood and affect – states anxious mood, but flat affect
Thought content –delusions
Think abstractly – anxiety as alarm system
Insight – denies any problems
Judgment – drinks constantly to avoid emotions

13. Varieties of Interviews
The Diagnostic Interview
Unstructured
Free-form, content varies greatly between clinicians
Structured
Standard set of questions and follow-up probes in a specific sequence
All patients asked the same questions
More likely that two clinicians will come to similar conclusions (high inter-rater reliability)
Often not really done in private practice with high-functioning clients. More important in cases where insurance will be billed, or when diagnosis needs to be documented (e.g., large hospitals, VA).

14. Overview – Day 5 Goals of assessment Rapport Listening
Types of interviews
General intake
Mental status exam
Diagnostic interview
Reliability & validity of interviews

15. Reliability and Validity of Interviews
Inter-rater reliability
Test-retest reliability
Inter-rater - The level of agreement between at least two raters who have evaluated the same patient independently
Test-retest - The consistency of interview scores over time

16. Validity of Interviews
Content – does an interview for depression assess both depressed mood and decreased motivation?
Predictive – does an interview for depression predict the level of impairment (say days of work missed) over the following month?
Concurrent – does an interview for depression correlate with self-report symptom measures
Construct – Are scores on an interview for depression correlated with sleep, mood, energy, but less or uncorrelated with intelligence, psychosis, etc.

17. Reliability and Validity of Interviews
Suggestions for Improving Reliability and Validity
Whenever possible, use a structured interview
If one does not exist for your purpose, consider developing one
Develop good interviewing skills
Be aware of the patient’s motives and expectancies
Be aware of your own expectations, biases, and cultural values
Example from my experience: recently homeless African American man with diagnosis of schizophrenia reporting various instances of racist behavior –
Important to keep him on track
Important to have him feel understood without agreeing that everything he says is 100% true
Consider his potential motives for increasing appearance of pathology (homeless benefits, disability, etc.)
Important to not assume that these reports are accounted for by delusions of persecution

18. Take-Home Assessment is important!
Assessment involves both collecting information and laying the foundation for a therapeutic relationship
There are different types of interviews that are important in different situations